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Identifying Intervention Strategies for Preventing the Mental Health Consequences of Childhood Adversity: a Modified Delphi Study

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Identifying Intervention Strategies for Preventing the Mental Health Consequences of Childhood Adversity: a Modified Delphi Study Development and Psychopathology (2021), 33, 748–765 doi:10.1017/S0954579420002059 Special Issue Article Identifying intervention strategies for preventing the mental health consequences of childhood adversity: A modified Delphi study Leslie R. Rith-Najarian1 , Noah S. Triplett2, John R. Weisz1 and Katie A. McLaughlin1 1Department of Psychology, Harvard University, Cambridge, MA, USA and 2Department of Psychology, University of Washington, Seattle, WA, USA Abstract Exposure to childhood adversity is a powerful risk factor for psychopathology. Despite extensive efforts, we have not yet identified effective or scalable interventions that prevent the emergence of mental health problems in children who have experienced adversity. In this modified Delphi study, we identified intervention strategies for effectively targeting both the neurodevelopmental mechanisms linking childhood adversity and psychopathology – including heightened emotional reactivity, difficulties with emotion regulation, blunted reward processing, and social information processing biases, as well as a range of psychopathology symptoms. We iteratively synthesized information from experts in the field and relevant meta-analyses through three surveys, first with experts in intervention development, prevention, and child- hood adversity (n = 32), and then within our study team (n = 8). The results produced increasing stability and good consensus on interven- tion strategy recommendations for specific neurodevelopmental mechanisms and symptom presentations and on strength of evidence ratings of intervention strategies targeting youth and parents. More broadly, our findings highlight how intervention decision making can be informed by meta-analyses, enhanced by aggregate group feedback, saturated before consensus, and persistently subjective or even contradictory. Ultimately, the results converged on several promising intervention strategies for prevention programming with adver- sity-exposed youth, which will be tested in an upcoming clinical trial. Keywords: childhood adversity, Delphi study, intervention development, prevention, psychopathology (Received 29 October 2020; accepted 31 October 2020) Introduction Miller, 2016; Felitti et al., 1998; Wegman & Stetler, 2009). A sub- stantial body of work has characterized the developmental mech- Exposure to adversity is common in children, both in the USA anisms through which experiences of adversity influence risk for and internationally. Approximately half of all US children will psychopathology and chronic diseases (Cicchetti & Toth, 1995; experience at least one form of adversity – such as physical, sex- Danese & McEwen, 2012; McLaughlin, 2016; McLaughlin, ual, or emotional abuse, neglect, exposure to interpersonal vio- Colich, Rodman, & Weissman, 2020; McLaughlin & Lambert, lence, or chronic poverty – by the time they reach adulthood 2017). Although knowledge of these mechanisms has grown dra- (Benjet et al., 2009; Green et al., 2010; Kessler et al., 2010; matically, little progress has been made in translating those mech- McLaughlin et al., 2012). Evidence from population-based and anisms into interventions to prevent the onset of psychopathology longitudinal studies demonstrates that experiences of adversity on subsequent consequences (McLaughlin, DeCross, Jovanovic, & are associated with the onset of internalizing and externalizing Tottenham, 2019). Through our current work, we hope to carry psychopathology transdiagnostically, including anxiety, mood, on Edward Zigler’s legacy of “be[ing] totally committed to the disruptive behavior, posttraumatic stress, and substance use disor- optimal development of each child” by developing such an inter- ders (Cohen, Brown, & Smailes, 2001; Green et al., 2010; Kessler vention for children who have screened positive for adversity. In et al., 2010; MacMillan et al., 2001; McLaughlin, Conron, Koenen, contrast to the scarcity of research available prior to the develop- & Gilman, 2010; McLaughlin et al., 2012; Weich, Patterson, Shaw, ment of Head Start, considered “the prototype of effective early & Stewart-Brown, 2009). Exposure to childhood adversity childhood intervention,” we are fortunate to now be able to explains about a third of mental disorder onsets in the USA draw on the substantial evidence base supporting early childhood (Green et al., 2010; McLaughlin et al., 2012) and is associated intervention (Zigler & Styfco, 2001). with increased risk for a wide range of chronic diseases and In theory, screening and early intervention could help early mortality (Brown et al., 2009; Chen, Turiano, Mroczek, & adversity-exposed children by preventing future incidences of adversity along with its physical and mental health consequences. Author for Correspondence: Leslie Rith-Najarian, Department of Psychology, We agree with the belief that children who begin life healthy Harvard University, Room 1006, William James Hall, 33 Kirkland St, Cambridge, MA “grow to become contributing members of the society, [and] 02138, USA; E-mail: [email protected] the small investment made in their early years will have com- Cite this article: Rith-Najarian LR, Triplett NS, Weisz JR, McLaughlin KA (2021). pounded to reap a handsome dividend” (Zigler, 1996, p. 47). Identifying intervention strategies for preventing the mental health consequences of childhood adversity: A modified Delphi study. Development and Psychopathology 33, A 10% reduction in childhood adversity prevalence in the USA 748–765. https://doi.org/10.1017/S0954579420002059 has been estimated to save $105 billion annually (Bellis et al., © The Author(s), 2021. Published by Cambridge University Press Downloaded from https://www.cambridge.org/core. 09 May 2021 at 21:57:36, subject to the Cambridge Core terms of use. Development and Psychopathology 749 2019). The broader the scale of screening and prevention efforts, PTSD but also with transdiagnostic psychopathology, including the greater the potential impact becomes. Pediatric primary care is a wide range of internalizing and externalizing problems (Green a promising setting for wide-reaching adversity screening and et al., 2010; Keyes et al., 2012; McLaughlin et al., 2012). prevention efforts, as the majority of US children see a primary Furthermore, such existing evidence-based interventions were care provider annually (Chevarley, 2003). Moreover, addressing designed as treatments for children who have already developed child mental health concerns in a medical setting has myriad ben- symptoms of psychopathology following traumatic events and efits, including reduced stigma, cost, and family discomfort, as thus primarily focus on symptom reduction rather than prevent- well as improved outcomes (Asarnow, Rozenman, Wiblin, & ing the emergence of psychopathology. This distinction is impor- Zeltzer, 2015; Godoy et al., 2017; Kolko & Perrin, 2014). tant as the mechanisms that underlie symptom maintenance may Primary care settings are already increasingly integrating youth differ from those that contribute to the emergence of psychopa- mental health care (Aupont et al., 2013), with approximately thology following experiences of adversity. As such, prevention half of all visits now involving some type of behavioral or mental practices that target the developmental pathways linking adversity health concern (Martini et al., 2012). Simultaneously, there has to the onset of psychopathology – particularly mechanisms that been a movement encouraging pediatricians to screen for adver- are associated with transdiagnostic risk – may ultimately hold sity within routine primary care visits (Garner et al., 2012; the most promise. Pardee, Kuzma, Dahlem, Boucher, & Darling-Fisher, 2017). Many have argued that greater attention to the neurodevelop- One encouraging example in primary care settings is the Safe mental pathways linking childhood adversity with psychopathol- Environment for Every Kid (SEEK) program (Dubowitz, 2014; ogy is needed in order to improve our ability to effectively Dubowitz, Feigelman, Lane, & Kim, 2009), which includes a intervene with children who have encountered adversity validated short adversity screening tool and a brief intervention (Bentovim et al., 2020; Cicchetti & Toth, 2009; Manly, Kim, (5–15 min) of motivational interviewing and community resource Rogosch, & Cicchetti, 2001; Masten & Cicchetti, 2010; referrals for families who endorse adversity experiences McLaughlin et al., 2019; van IJzendoorn et al., 2020). Over the (Dubowitz et al., 2007; Dubowitz, Prescott, Feigelman, Lane, & past decade, a substantial body of evidence has emerged on Kim, 2008; Feigelman et al., 2009; Lane et al., 2007). these mechanisms. As noted in recent reviews of this literature, Randomized controlled trials of SEEK have shown reduced rates developmental pathways that have garnered the most consistent of future child maltreatment (Dubowitz et al., 2009; Dubowitz, evidence for being influenced by experiences of adversity and Lane, Semiatin, & Magder, 2012), and feasibility studies have that, in turn, are associated with the later onset of psychopathol- shown high acceptability and satisfaction among providers and ogy include threat-related social information processing biases caregivers in primary care settings (e.g., Eismann, Theuerling, (e.g., hostile attribution bias), heightened emotional reactivity, dif- Maguire, Hente, & Shapiro, 2019). However, despite all this pro- ficulties with emotion regulation, and blunted reward processing gress, one concern about adversity screening
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